Synopsis

This compelling and inspiring book, now in a deluxe paperback edition, shows how one person can work wonders. In Mountains Beyond Mountains, Pulitzer Prize—winning author Tracy Kidder tells the true story of a gifted man who loves the world and has set out to do all he can to cure it.

In medical school, Paul Farmer found his life’s calling: to cure infectious diseases and to bring the lifesaving tools of modern medicine to those who need them most. Kidder’s magnificent account takes us from Harvard to Haiti, Peru, Cuba, and Russia as Farmer changes minds and practices through his dedication to the philosophy that “the only real nation is humanity.” At the heart of this book is the example of a life based on hope and on an understanding of the truth of the Haitian proverb “Beyond mountains there are mountains”–as you solve one problem, another problem presents itself, and so you go on and try to solve that one too.

“Mountains Beyond Mountains unfolds with a force of gathering revelation,” says Annie Dillard, and Jonathan Harr notes, “[Paul Farmer] wants to change the world. Certainly this luminous and powerful book will change the way you see it.”

Excerpt

Chapter 1

Six years after the fact, Dr. Paul Edward Farmer reminded me, “We met because of a beheading, of all things.”

It was two weeks before Christmas 1994, in a market town in the central plateau of Haiti, a patch of paved road called Mirebalais. Near the center of town there was a Haitian army outpost–a concrete wall enclosing a weedy parade field, a jail, and a mustard-colored barracks. I was sitting with an American Special Forces captain, named Jon Carroll, on the building’s second-story balcony. Evening was coming on, the town’s best hour, when the air changed from hot to balmy and the music from the radios in the rum shops and the horns of the tap-taps passing through town grew loud and bright and the general filth and poverty began to be obscured, the open sewers and the ragged clothing and the looks on the faces of malnourished children and the extended hands of elderly beggars plaintively saying, “Grangou,” which means “hungry” in Creole.

I was in Haiti to report on American soldiers. Twenty thousand of them had been sent to reinstate the country’s democratically elected government, and to strip away power from the military junta that had deposed it and ruled with great cruelty for three years. Captain Carroll had only eight men, and they were temporarily in charge of keeping the peace among 150,000 Haitians, spread across about one thousand square miles of rural Haiti. A seemingly impossible job, and yet, out here in the central plateau, political violence had all but ended. In the past month, there had been only one murder. Then again, it had been spectacularly grisly. A few weeks back, Captain Carroll’s men had fished the headless corpse of the assistant mayor of Mirebalais out of the Artibonite River. He was one of the elected officials being restored to power. Suspicion for his murder had fallen on one of the junta’s local functionaries, a rural sheriff named Nerva Juste, a frightening figure to most people in the region. Captain Carroll and his men had brought Juste in for questioning, but they hadn’t found any physical evidence or witnesses. So they had released him.

The captain was twenty-nine years old, a devout Baptist from Alabama. I liked him. From what I’d seen, he and his men had been trying earnestly to make improvements in this piece of Haiti, but Washington, which had decreed that this mission would not include “nation-building,” had given them virtually no tools for that job. On one occasion, the captain had ordered a U.S. Army medevac flight for a pregnant Haitian woman in distress, and his commanders had reprimanded him for his pains. Up on the balcony of the barracks now, Captain Carroll was fuming about his latest frustration when someone said there was an American out at the gate who wanted to see him.

There were five visitors actually, four of them Haitians. They stood in the gathering shadows in front of the barracks, while their American friend came forward. He told Captain Carroll that his name was Paul Farmer, that he was a doctor, and that he worked in a hospital here, some miles north of Mirebalais.

I remember thinking that Captain Carroll and Dr. Farmer made a mismatched pair, and that Farmer suffered in the comparison. The captain stood about six foot two, tanned and muscular. As usual, a wad of snuff enlarged his lower lip. Now and then he turned his head aside and spat. Farmer was about the same age but much more delicate-looking. He had short black hair and a high waist and long thin arms, and his nose came almost to a point. Next to the soldier, he looked skinny and pale, and for all of that he struck me as bold, indeed downright cocky.

He asked the captain if his team had any medical problems. The captain said they had some sick prisoners whom the local hospital had refused to treat. “I ended up buyin’ the medicine myself.”

Farmer flashed a smile. “You’ll spend less time in Purgatory.” Then he asked, “Who cut off the head of the assistant mayor?”

“I don’t know for sure,” said the captain.

“It’s very hard to live in Haiti and not know who cut off someone’s head,” said Farmer.

A circuitous argument followed. Farmer made it plain he didn’t like the American government’s plan for fixing Haiti’s economy, a plan that would aid business interests but do nothing, in his view, to relieve the suffering of the average Haitian. He clearly believed that the United States had helped to foster the coup–for one thing, by having trained a high official of the junta at the U.S. Army’s School of the Americas. Two clear sides existed in Haiti, Farmer said–the forces of repression and the Haitian poor, the vast majority. Farmer was on the side of the poor. But, he told the captain, “it still seems fuzzy which side the American soldiers are on.” Locally, part of the fuzziness came from the fact that the captain had released the hated Nerva Juste.

I sensed that Farmer knew Haiti far better than the captain, and that he was trying to impart some important information. The people in this region were losing confidence in the captain, Farmer seemed to be saying, and this was a serious matter, obviously, for a team of nine soldiers trying to govern 150,000 people.

But the warning wasn’t entirely plain, and the captain got a little riled up at Farmer’s denunciation of the School of the Americas. As for Nerva Juste, he said, “Look, that guy is a bad guy. When I do have him and the evidence, I’ll slam him.” He slapped a fist into his hand. “But I’m not gonna stoop to the level of these guys and make summary arrests.”

Farmer replied, in effect, that it made no sense for the captain to apply principles of constitutional law in a country that at the moment had no functioning legal system. Juste was a menace and should be locked up.

So they reached a strange impasse. The captain, who described himself as “a redneck,” arguing for due process, and Farmer, who clearly considered himself a champion of human rights, arguing for preventive detention. Eventually, the captain said, “You’d be surprised how many decisions about what I can do here get made in Washington.”

It had grown dark. The two men stood in a square of light from the open barracks door. They shook hands. As the young doctor disappeared into the shadows, I heard him speaking Creole to his Haitian friends.

I stayed with the soldiers for several weeks. I didn’t think much about Farmer. In spite of his closing words, I didn’t think he understood or cared to sympathize with the captain’s problems.

Then by chance I ran into him again, on my way home, on the plane to Miami. He was sitting in first-class. He explained that the flight attendants put him there because he often flew this route and on occasion dealt with medical emergencies on board. The attendants let me sit with him for a while. I had dozens of questions about Haiti, including one about the assistant mayor’s murder. The soldiers thought that Voodoo beliefs conferred a special, weird terror on decapitation. “Does cutting off the victim’s head have some basis in the history of Voodoo?” I asked.

“It has some basis in the history of brutality,” Farmer answered. He frowned, and then he touched my arm, as if to say that we all ask stupid questions sometimes.

I found out more about him. For one thing, he didn’t dislike soldiers. “I grew up in a trailer park, and I know which economic class joins the American military.” He told me, speaking of Captain Carroll, “You meet these twenty-nine-year-old soldiers, and you realize, Come on, they’re not the ones making the bad policies.” He confirmed my impression, that he’d visited the captain to warn him. Many of Farmer’s patients and Haitian friends had complained about the release of Nerva Juste, saying it proved the Americans hadn’t really come to help them. Farmer told me he was driving through Mireba- lais and his Haitian friends were teasing him, saying he didn’t dare stop and talk to the American soldiers about the murder case, and then the truck got a flat tire right outside the army compound, and he said to his friends, “Aha, you have to listen to messages from angels.”

I got Farmer to tell me a little about his life. He was thirty-five. He had graduated from Harvard Medical School and also had a Ph.D. in anthropology from Harvard. He worked in Boston four months of the year, living in a church rectory in a slum. The rest of the year he worked without pay in Haiti, mainly doctoring peasants who had lost their land to a hydroelectric dam. He had been expelled from Haiti during the time of the junta but had sneaked back to his hospital. “After the payment,” he said, “of an insultingly small bribe.”

I looked for him after the plane landed. We talked some more in a coffee shop, and I nearly missed my connecting flight. A few weeks later, I took him to dinner in Boston, hoping he could help make sense of what I was trying to write about Haiti, which he seemed glad to do. He clarified some of the history for me but left me wondering about him. He had described himself as “a poor people’s doctor,” but he didn’t quite fit my preconception of such a person. He clearly liked the fancy restaurant, the heavy cloth napkins, the good bottle of wine. What struck me that evening was how happy he seemed with his life. Obviously, a young man with his advantages could have been doing good works as a doctor while commuting between Boston and a pleasant suburb–not between a room in what I imagined must be a grubby church rectory and the wasteland of central Haiti. The way he talked, it seemed he actually enjoyed living among Haitian peasant farmers. At one point, speaking about medicine, he said, “I don’t know why everybody isn’t excited by it.” He smiled at me, and his face turned bright, not red so much as glowing, a luminescent smile. It affected me quite strongly, like a welcome gladly given, one you didn’t have to earn.

But after our dinner I drifted out of touch with him, mainly, I now think, because he also disturbed me. Writing my article about Haiti, I came to share the pessimism of the soldiers I’d stayed with. “I think we should have left Haiti to itself,” one of Captain Carroll’s men had said to me. “Does it really matter who’s in power? They’re still gonna have the rich and the poor and no one in between. I don’t know what we hope to accomplish. We’re still going to have a shitload of Haitians in boats wanting to go to America. But, I guess it’s best not even to try and figure it out.” The soldiers had come to Haiti and lifted a terror and restored a government, and then they’d left and the country was just about as poor and broken-down as when they had arrived. They had done their best, I thought. They were worldly and tough. They wouldn’t cry about things beyond their control.

I felt as though, in Farmer, I’d been offered another way of thinking about a place like Haiti. But his way would be hard to share, because it implied such an extreme definition of a term like “doing one’s best.”

The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money. Over the next five years, I mailed some small sums to the charity that supported Farmer’s hospital in Haiti. He sent back handwritten thank-you notes on each occasion. Once, from a friend of a friend, I heard he was doing something notable in international health, something to do with tuberculosis. I didn’t look into the details, though, and I didn’t see him again until near the end of 1999. I was the one who made the appointment. He named the place.

About Tracy Kidder

Tracy Kidder graduated from Harvard and studied at the University of Iowa. He has won the Pulitzer Prize, the National Book Award, the Robert F. Kennedy Award, and many other literary prizes. The author of Mountains Beyond Mountains, My Detachment,Home Town, Old Friends, Among Schoolchildren, House, and The Soul of a New Machine, Kidder lives in Massachusetts and Maine.

Author Q&A

A Conversation with Tracy Kidder, author of MOUNTAINS BEYOND MOUNTAINS

Q: How did you meet Paul Farmer, and what made you want to write about him?A: I met him in Haiti in 1994. I was doing a story on American soldiers sent there to reinstate the country’s democratically elected government. Farmer showed up one night at the barracks and got into an argument with the commander. I wasn’t very interested in him then, but a few weeks later I ran into him on the plane to Miami and I began to learn some of the outlines of his life, which I found very interesting. Farmer was the second of six children, and spent most of his childhood in Florida, the whole family living on a bus and a houseboat that was moored in a bayou on the Gulf Coast. He went to Duke on a full scholarship, and then, while he was earning his M.D. and Ph.D at Harvard, he conceived and helped to build an amazing health care system in one of the poorest corners of Haiti. Around the time when I met him, he and his small band of colleagues were about to go to war against the dominant ideologies in international health — eventually they’d actually win some significant battles.And I was drawn to the man himself. He worked extraordinary hours. In fact, I don’t think he sleeps more than an hour or two most nights. Here was a person who seemed to be practicing more than he preached, who seemed to be living, as nearly as any human being can, without hypocrisy. A challenging person, the kind of person whose example can irritate you by making you feel you’ve never done anything as important, and yet, in his presence, those kinds of feelings tended to vanish. In the past, when I’d imagined a person with credentials like his, I’d imagined someone dour and self-righteous, but he was very friendly and irreverent, and quite funny. He seemed like someone I’d like to know, and I thought that if I did my job well, a reader would feel that way, too. My favorite teacher once used to talk about how writers often have their best stories bestowed upon them, seemingly by accident. I felt as though, in meeting Farmer, I’d been offered a rare opportunity.

Q: What was Farmer’s initial response to your wanting to write a book about him and his work?A: I think the idea made him uncomfortable. At any rate, it took him some months to make the decision. I can’t speak for him, but I think he agreed mainly because he was persuaded by some of his closest friends that a book about his life and work might bring attention both to the issues that he cares most about and also to the little organization that he helped to create — Partners In Health.

Q: What was involved in doing the research for this book?A: A lot of time in airplanes. I traveled with Farmer to Haiti more times than I can now remember. I also went with him twice to Moscow, and to Siberia, to Peru, to Cuba, to Paris, to Chiapas in Mexico, to Montreal and New York City and, many times, to Boston. And I went to Geneva, Switzerland, with one of his closest colleagues. I also visited his mother and some of his siblings, and the places of his childhood. I interviewed dozens of people. And I read a great deal, about medicine and public health, about the places where Farmer works, especially about Haiti.

Q: What does the title, MOUNTAINS BEYOND MOUNTAINS, mean?A: The title comes from a Haitian proverb, which is usually translated as: “Beyond the mountains, more mountains.” According to Farmer, a better translation is: “Beyond mountains there are mountains.” I first heard the proverb from Farmer, and I remember that he told me, “The Haitians, of course, use it in a zillion different ways.” Sometimes it’s used to express the idea that opportunities are inexhaustible, and sometimes as a way of saying that when you surmount one great obstacle you merely gain a clear view of the next one. Of course, those two meanings aren’t inconsistent, and I meant to imply both in the title. To me, the phrase expresses something fundamental about the spirit and the scale and the difficulty of Farmer’s work. The Haitian proverb, by the way, is also a pretty accurate description of the topography of a lot of Haiti, certainly as I experienced it in my hikes with Farmer through the mountains of the central plateau.Q: Farmer didn’t have a conventional upbringing. Tell us more about that. Do you think Farmer’s childhood was influential in the path he’s chosen?A: Farmer’s father was a great big man, a ferociously competitive athelete nicknamed Elbows by people who played basketball with him, a sometime salesman and school teacher, with a lot of unconventional ideas and an absolutely pig-headed determination to have his family live by them. He took his family to a town north of Tampa, Florida, where for about five years they all lived in a bus in a campground. Then he took them to a bayou on the Gulf Coast where all eight of them lived in a leaky old 50 foot-long boat. As a boy, Farmer thrived in these unusual circumstances. He was a tall, skinny kid and he disappointed his father by not being much of an athelete, but he excelled in every intellectual department. He seems to have been precocious spiritually as well. At 11 he was given a copy of Tolkien’s Lord of the Rings, which he read and then immediately re-read in the space of a few days. Then he took it to the public library and said to the woman at the desk, “I want more books like this.” She gave him adventure and fantasy novels and he kept coming back and saying, “This isn’t it.” Finally, she gave him Tolstoy’s War and Peace, which he devoured, at the age of 11. It wasn’t adventure or fantasy that interested him; it was the epic struggle between good and evil. He didn’t have the words to say that then. Returning the library’s copy of War and Peace, he simply told the librarian, “This is it! This is just like Lord of the Rings.”It was a childhood full of family adventures and misadventures and completely unconventional. Farmer himself didn’t like to make too much of the connections between his background and the life he chose. At the very least, though, that childhood was good preparation for a life of travel and doctoring in difficult places like Haiti. He emerged from living on a boat in a bayou with what he called a “very compliant GI system,” and from dinners of hot dog bean soup without much fussiness about food, and from years of cramped quarters with the ability to concentrate anywhere. He could sleep in a dentist’s chair, as he did at night for most of one summer in a clinic in Haiti, and consider it an improvement over other places he had slept, and I imagine that his fondness for a fine hotel and a good bottle of wine had the same origins.

There were other advantages, Farmer insisted. The kind of father who thought it reasonable to house his family in a bus, then a boat, was also the kind who saw no reason his son shouldn’t keep a large acquarium inside. Farmer insisted that he never really felt deprived throughout his childhood, though he did admit, “It was pretty strange.” After living through some of his father’s very public misadventures, it was hard to feel embarrassed or shy in front of anyone. He allowed that growing up as he did also probably relieved him of a homing instinct. “I never had a sense of a home town. It was, ‘This is my campground.’ Then I got to the bottom of the barrel, and it was ‘Oh, this is my hometown.’” He meant the central plateau of Haiti.

Q: In your travels with Farmer, what most surprised and interested you? Did you learn something from the experience?A: The thing about travel with Farmer is that you don’t visit the brochure sights. His itinerary is pretty much restricted to visiting hospitals, slums, and prisons. The dreadful places of the world. I hadn’t imagined that there were so many of those, and I hadn’t known just how dreadful they were. But the trips weren’t dreary and depressing, because Farmer and his colleagues were doing something tangible, something meaningful, something that was actually improving those places. This was especially true in Haiti and Peru. I’d say that I learned two things above all. That medicine and public health are a powerful lens for looking at the world. And that a small group of determined people can actually alter some of the pictures seen through that lens. I think that as a very young man Farmer chose to work in one of the most impoverished parts of Haiti because he was moved by the suffering he saw there. But if he’d wanted to prove a point about what is possible in public health, he couldn’t have chosen a better site. If you can do a good thing in central Haiti, it stands to reason that you can do it anywhere. And what he and his friends have done and are doing in Haiti — and elsewhere - is nothing short of remarkable. Q: Has your life or outlook about life changed as a result of spenind time with Farmer and writing this book?A: One of my favorite characters in this book is a woman named Ophelia Dahl. She met Paul Farmer when she was 18 and he was 23. She told me that she remembered, from many years ago, deciding that Farmer was an important person to believe in. Not as a figure to watch from a distance, thinking, Oh, look, there is good in the world. Not as a comforting example, but the opposite. As proof that it was possible to put up a fight. As a goad to make others realize that if people could be kept from dying unnecessarily — from what Haitians call “stupid deaths” — then one had to act. I don’t plan to give away all my worldly goods and go to work with Farmer in Haiti. For one thing, I’d just get in the way. But I can’t tell myself anymore that the great problems of the world, such as the AIDS and TB epidemics, are beyond all hope of amelioration, or of repair. In other words, I don’t think I can feel comfortable anymore in this world, by resigning myself to despair on behalf of billions of other people. There’s always something one can do. It’s not my place to make a fund-raising pitch for Farmer and his organization, Partners In Health. Well, actually, I don’t know why it isn’t my place. I happened onto something remarkable and I sat down to try to describe it to others. I hope what I’ve written is artful. I believe it is at least accurate and truthful. And one true fact is that Farmer’s organization, Partners In Health, represents a real antidote to despair. A person with a little money to give away can send it to Partners In Health and be certain that it will be used well. 95 percent of the money that’s donated to Partners In Health goes to pay for direct services to people who are both desitute and sick — in Boston, in Russia, in Chiapas, in Peru, and especially in Haiti, where the poorest and the sickest people in our hemisphere reside. A donation to Partners In Health of, say, $200 will save an impoverished Haitian from dying a horrible death from tuberculosis. Q: How does this book differ from your other projects?A: Well, for one thing this book has a pretty large geographical spread, whereas all my previous books are set in New England. And all the others are about what might be called “ordinary people.” Of course, no one is ordinary. But Farmer is less ordinary than anyone I’ve ever met. This is the main reason I wrote this book in the first person, something I’d done in only one other book. After I’d spent a lot of time with Farmer, I began to feel that altruism was plausible after all, indeed maybe even normal. But the sacrifices he’s made aren’t usual, and I knew that readers of my book would need an everyman, someone a lot less virtuous than Farmer, to interpret him and to make him believable. Someone to testify, in effect, that this guy is for real, and someone who could register the occasional discomfort that anyone would feel in such a person’s company. Finally, although I like to think that the subjects I’ve written about in my other books are important, I don’t think there’s much question but that the subject of this book is more important. After all, what it’s about at bottom is the attempt of one small group of people to heal a sick world.

Q: Farmer doesn’t work alone. He is surrounded by some extraordinary people. Can you tell us a little about some of them?A: There are more than a thousand people working for Partners In Health these days. They range from Haitian peasants who have been trained as community health workers to extremely bright young American epidemiologists, medical students, and doctors, who have enlisted to work in places such as central Haiti and Siberia and the slums of Lima, Peru - some of them work for nothing, some earn much less than they could elsewhere and some raise their own salaries through grants. Ophelia Dahl has been involved in Farmer’s work from the start, and she’s a crucial member of Partners In Health, the manager, the peacekeeper. She’s a warm and charming person, and she knows how to manage Farmer and Farmer’s colleague, Jim Yong Kim. Kim is, like Farmer, a Brigham doctor. He joined up only a few months after Partners In Health was founded. He’s brilliant, an inspiring speaker, a fountain of ideas, and indefatigable. Finally, and maybe most important, there’s a man named Tom White. He built a small family business into one of the largest heavy construction firms in Boston. He and Farmer met when Farmer was still a doctor in training. He founded Partners In Health along with Farmer and until recently provided most of the money for its projects, millions and millions of dollars over the past 20 years. White is in his eighties now, and has given away almost all of his large fortune. He told me once, “Sometimes I think how much money I used to have before I met Paul and Jim. But that’s all right. If I go to a restaurant and they give me a steak, I can only eat half of it anymore.” He plans, he told me, to leave this life without a nickel. I think it’s accurate to say that White has lifted death sentences from thousands of people, and the organization, the movement, that he helped to start may in the end save millions.

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Praise

Praise

“[A] masterpiece.”—USA Today

“Inspiring, disturbing, daring and completely absorbing.”—New York Times Book Review

“Stunning. Mountains Beyond Mountains will move you, restore your faith in the ability of one person to make a difference in these increasingly maddening, dispiriting times. [Kidder has] held his writer’s mirror up to an astonishing comet of a man whose reflection flatters us all for what it says about our capacity for mercy and healing.”—San Diego Union-Tribune

“Easily the most fascinating, most entertaining and, yes, most inspiring work of non-fiction I’ve read this year.”—San Jose Mercury News

“It’ll fill you equally with wonder and hope.”—People

“If I ever go on a retreat again, this is the kind of book I’d like to take for spiritual reading. . . . [Kidder] knows it is impossible to live like Farmer, but the impossibility is the very thing that can somehow give us life.”—Washington Post Book World

“In this excellent work, Pulitzer Prize—winner Kidder immerses himself in and beautifully explores the rich drama that exists in the life of Dr. Paul Farmer…Throughout, Kidder captures the almost saintly effect Farmer has on those whom he treats.”—Publishers Weekly, starred review

“[A] Skilled and graceful exploration of the soul of an astonishing human being.”—Kirkus Reviews, starred review

“A fine writer and his extraordinary subject: Tracy Kidder, in giving us Paul Farmer, lifts up an image of hope–and challenge–that the world urgently needs. Simply put, this is an important book.” -James Carroll, author of Constantine's Sword

“The central character of this marvelous book is one of the most provocative, brilliant, funny, unsettling, endlessly energetic, irksome, and charming characters ever to spring to life on the page. He has embarked on an epic struggle that will take you from the halls of Harvard Medical School to a sun-scorched plateau in Haiti, from the slums of Peru to the cold gray prisons of Moscow. He wants to change the world. Certainly this luminous and powerful book will change the way you see it.”—Jonathan Harr, author of A Civil Action

“A profoundly inspiring and important book about one of the truly great men of our time.” —Ethan Canin, author of Carry Me Across the Water

“Here is a genuine hero alive in our times. Mountains Beyond Mountains unfolds with the force of gathering revelation. Like all of Tracy Kidder’s books, it is as hard to put down as any good and true story.”—Annie Dillard, author of The Writing Life

“Mountains Beyond Mountains is the only book I’ve read in years that made me feel like cheering. It left me uncomfortable, guilty, and exhausted—but it also inspired me, kept me up all night, and moved me to tears. Some readers will find their lives changed forever; everyone else will emerge, at the very least, with an unexpectedly revised set of values. Tracy Kidder has given us not only an unforgettable book but an unignorable life lesson. Hurrah!” —Anne Fadiman, author of The Spirit Catches You and You Fall Down

“Rarely has idealism fared so well on the planet as in Tracy Kidder’s eloquently reported Mountains Beyond Mountains. One is tempted to call Paul Farmer’s passionate sensibilities and loving ambitions otherworldly, but only in sadness that there are too few of him in the world. Kidder has provided us all, as the Farmerites say, with a road map to decency, and such an endowment is beyond measure.” —Bob Shacochis, author of Easy in the Islands

"Is there anything Tracy Kidder can't do? This is a beautiful book, and a masterful one. Even better, Mountains Beyond Mountains is a page-turner that will crack your conscience open." -Stacey Schiff, author of Vera

“An incredible story about an incredible man told by an incredible writer. Mountains Beyond Mountains is the sort of book that makes you want to buy a hundred copies and pass them out like a street corner evangelist. It's the sort of book that will affect your life in a profound way. In a good way.” -Thom Jones, author of The Pugilist at Rest

“Saints are notoriously difficult people, but who knew one could be so funny, so utterly charming, and finally so deft in accomplishing that most impossible of all job descriptions—changing the world? Tracy Kidder's spellbinding story presents us with an unlikely saint and finally, with inspiration so compelling it makes the usual cynicism about global change seem indulgent foolishness.”—Patricia Hampl, author of A Romantic Education

Discussion Questions|Teachers Guide

Discussion Guides

1. Paul Farmer finds ways of connecting with people whose backgrounds are vastly different from his own. How does he do this? Are his methods something to which we can all aspire?

2. Paul Farmer believes that “if you’re making sacrifices . . . you’re trying to lessen some psychic discomfort” (p. 24). Do you agree with the way that Farmer makes personal sacrifices? For what kinds of things do you make sacrifices, and when do you expect others to make them?

3. Kidder points out that Farmer is dissatisfied with the current distribution of money and medicine in the world.What is your opinion of the distribution of these forms of wealth? What would you change, if you could?

4. Farmer designed a study to find out whether there was a correlation between his Haitian patients’ belief in sorcery as the cause of tb and their recovery from that disease through medical treatment.What did he discover about the relative importance of cultural beliefs among his impoverished patients and their material circumstances? Do you think that this discovery might have broad application–for instance, to situations in the United States?

5. The title of the book comes from the Haitian proverb,“Beyond mountains there are mountains.” What does the saying mean in the context of the culture it comes from, and what does it mean in relation to Farmer’s work? Can you think of other situations–personal or societal–for which this proverb might be apt?

6. Paul Farmer had an eccentric childhood, and his accomplishments have been unique. Do you see a correlation between the way Farmer was raised and how he has chosen to live his life? How has your own background influenced your life and your decisions?

7. Compare Zanmi Lasante to the Socios en Salud project in Carabayllo. Consider how the projects got started, the relationships between doctors and patients, and the involvement of the international community.

8. Kidder explains that Farmer and his colleagues at PIH were asked by some academics, “Why do you call your patients poor people? They don’t call themselves poor people” (p. 100). How do Farmer and Jim Kim confront the issue of how to speak honestly about the people they work to help? How do they learn to speak honestly with each other, and what is the importance of the code words and acronyms that they share (for example, amc’s, or Areas of Moral Clarity)?

9. Ophelia Dahl and Tom White both play critical roles in this book and in the story of Partners In Health. How are their acts of compassion different from Farmer’s?

10. Tracy Kidder has written elsewhere that the choice of point of view is the most important an author makes in constructing a work of narrative nonfiction. He has also written that finding a point of view that works is a matter of making a choice among tools, and that the choice should be determined not by theory, but by an author’s immersion in the materials of the story itself. Kidder has never before written a book in which he made himself a character. Can you think of some of the reasons he might have had for doing this in Mountains Beyond Mountains?

Teacher's Guide

NOTE TO TEACHERS

Teachers: If you'd like a printable version of this guide, download the PDF attachment at the bottom of this page.

Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the Worldtells the true story of one man’s commitment to bring quality health care to the world’s poorest communities. Author Tracy Kidder guides students through many physical and philosophical journeys with Dr. Farmer, eloquently articulating Farmer’s mission of correcting the inequities and epidemics that plague the poorest people. These journeys with Dr. Farmer constitute an adventure story focused on critical moral issues.

Mountains Beyond Mountains raises several profound questions about issues of access to health care and the global distribution of wealth, allowing students a glimpse into Dr. Farmer’s work to change the world. Reading this fascinating and inspiring book with your class will provide an opportunity to discuss critical modern political issues and will challenge your students to reflect on their own goals and personal philosophies.

This guide is divided into three categories: Style and Structure, Comprehension and Discussion, and Personal Essays. Questions in the first two sections can be used for oral discussion in small or large groups, or for written assignments. The Personal Essay questions will require longer, personal answers, and are more appropriate as written assignments. Each section can be individualized for your students’ interests and reading level, or adapted to meet curriculum demands.

ABOUT THIS AUTHOR

Tracy Kidder was born in New York City in 1945. He attended Harvard College and served as a lieutenant in Vietnam. He writes frequently for Atlantic Monthly magazine and The New Yorker.

After briefly meeting Paul Farmer in Haiti in 1994, Kidder met up with him again in 1999 to begin work on “The Good Doctor,” a profile of Farmer that was published in The New Yorker in July 2000. Kidder’s research for The New Yorker article became the starting point for Mountains Beyond Mountains.

Tracy Kidder won the Pulitzer Prize and the National Book award in 1982 for The Soul of the New Machine, a book about corporate, high-tech America. Other works include House (1985), Among Schoolchildren (1989), Old Friends (1993), and Home Town (1999). His next book, My Detachment: A Memoir (due Fall 2005) focuses on his time spent as a lieutenant in Vietnam.

TEACHING IDEAS

Style and Structure1. Kidder opens Mountains Beyond Mountains with an account of a discussion between Paul Farmer and a U.S. army captain who was commanding a small peacekeeping force in Haiti. Farmer and the captain initially discuss a recent murder case in the area, and then move on to discuss the role of the U.S. in Haiti. While the U.S. Army troops had been stationed in Haiti to reinstate the country’s democratically elected government and to curb political violence, some of the soldiers were cynical about the effects of their presence in the country. In his reflections on the work of the soldiers, Kidder acknowledges that he shared the soldiers’ pessimism, believing that they “had done their best” and that they “would not cry over things beyond their control” in Haiti (page 8). Why do you think that Kidder opens his book with this scene?

2. Most of Tracy Kidder’s other books are not written in the first-person voice. Why do you think he chose to write Mountains Beyond Mountains from a first-person perspective? In what ways would the book be different if it were written in the third-person perspective?

3. The title of the book, Mountains Beyond Mountains, is taken from a Haitian proverb that translates as “beyond mountains there are mountains.” Why did Kidder use this as the title? What does it mean in terms of Paul Farmer’s work?

DISCUSSION AND WRITING

1. On his trips outside of Haiti, Paul Farmer carries two photos to show his colleagues–one of his own daughter Catherine, and one of a young patient at Cange (page 213). Why is it important to Farmer to show both photos?

2. In Chapter 22, Kidder notes that Paul Farmer’s “days and nights looked hard and in some ways lonesome.” Farmer is very dedicated to his work and has been very successful but in order to do his work, he has also made many personal sacrifices. What sacrifices has Farmer made to pursue his goals? How have these sacrifices affected his relationship with Didi and Catherine, and with his friends?

3. Paul Farmer had a very unusual upbringing in Massachusetts, Alabama, and Florida. What specific elements from his childhood and family life prepared Farmer for his current life? How has your upbringing influenced your own choices and goals in life?

4. Throughout the book, Kidder describes Farmer’s interactions with patients. In many cases, Farmer tends to reach out to touch his patients comfortingly and call them by pet names or endearments. Are these gestures typical of modern American doctors? How do these gestures reflect Farmer’s philosophy of the role of a doctor?

5. What motivates Paul Farmer to do the work he does? What does he see as his compensation? (page 24)

6. Farmer’s philosophy is at odds with standard notions of efficiency and cost-effectiveness. His approach to public health care has drawn criticism because it is not perceived to be cost-effective. For instance, one critic commented that the $20,000 spent on transporting a sick Haitian child to Boston for treatment could have been better spent on other things, like supplies or drugs for many other children (page 287). What is his response to these arguments? What factors do you think are most important in making such decisions about how money should be spent in public health programs?

7. Paul has trained as a medical anthropologist and as a doctor. Discuss the difference between these two careers with your class. How has his background in medical anthropology complemented his work as a doctor? What specific scenes illustrate Farmer’s skills as a medical anthropologist?

8. What is meant by the phrase, “All suffering isn’t equal” on page 216? How does this belief shape the work that Paul Farmer, Jim Kim, and Partners in Health do?

9. As Partners in Health grows, Farmer is expected to travel to many places to implement and monitor programs, meet with policy-makers and other doctors, and make presentations on public health issues. His increasing involvement in other programs in Peru and Russia requires that he spend less time in Cange (page 260). How does he describe the inner conflict between serving his patients in Haiti and helping to solve international inequities and epidemics globally?

10. Many people in Cange believe that Paul Farmer “works with both hands,” meaning that he works both with science and with the magic necessary to remove Voodoo curses (page 27). How did he learn about the role of Voodoo in the lives of the residents of Cange? How does Farmer interpret the continuing presence of Voodoo in modern Haitian life?

11. Early members of Partners in Health refer frequently to an idea from the Catholic liberation theology movement, of “preferential option for the poor” (pages 78 and 81). How does Farmer’s life and work reflect this particular theology? What are some other examples of the role of faith and religion in Paul Farmer’s work?

SUGGESTED ACTIVITIES

Personal Essay1. Do you think that Farmer has struck an appropriate balance between acting locally and acting globally? How do you think he should prioritize his responsibilities toward his Haitian patients, PIH’s other international programs, and the global public health community?

2. What responsibilities do you think individuals in wealthier nations have toward people in poor countries? How has reading this account of Paul Farmer’s work changed your ideas about your responsibility or obligations toward people who are poorer than you are? What do you think is the best way to express or act on this sense of responsibility?

3. In many of his projects and activities, Paul Farmer achieves his goals by subverting policies. For example, while there is officially a fee for patient services at Zanmi Lasante, he has made a long list of exceptions, so that in fact almost no one has to pay for services (page 21). While he was in medical school, he “borrowed” tens of thousands of dollars worth of drugs and lab services from Brigham and Young Hospital on behalf of his patients at Zanmi Lasante by charming the pharmacists and lab workers (page 149). How do you feel about his unconventional approach to problem solving? Do you think that he could be more effective by working within a framework of existing policies and institutional structures, or by working to change policies that he sees as oppressive to the poor?

4. In the final paragraph of the book, Kidder makes a reference to the time he spent with the American soldiers before he met Paul Farmer and of how he regarded the plight of the suffering people. In what ways have Kidder and his viewpoints changed since first meeting Farmer? How did your own perception of Farmer’s life and work change, if it did, as you read the book?

ABOUT THIS GUIDE

Reading Level: 10

This Teacher's Guide is recommended for use by high school educators.

About the Teacher's Guide Writer

Heather Kelly received her Master’s degree in Public Administration and Economic and Political Development from Columbia University’s School of International and Public Health and her Bachelor’s degree in English Literature from the College of William and Mary. She taught English at a high school in Papua New Guinea with the Peace Corps, and since then has worked on numerous international public health and economic development projects. She has worked with several non-governmental agencies and the United Nations Development Programme (UNDP) in East Timor, Nunavut, Tanzania, Kenya, and Uganda.